Is it time to radically change the two week wait (2WW) referral pathway for suspected brain and CNS cancer?

Abstract

BACKGROUND

In June 2015, the National Institute for Health and Care Excellence (NICE) published revised 2WW referral guidelines for general practitioners (GP) for patients with suspected brain and CNS cancer. The guidelines are comprehensive and include recommendations for using brain imaging and provision of relevant clinical information at referral.

METHODOLOGY

Retrospective audit of patients referred on 2WW pathway for suspected brain cancer to South Tees Trust between 1/7/2015 and 31/12/2017. Cases were identified from the Trust's 2WW referral database. Data were collected from referral letters and patient records. Quality of referral information was assessed in 10 domains.

RESULTS

122 patients identified. 98 cases audited (50F:48M, median age 61 years, range 16–92 years). 24 cases excluded: non-brain/CNS 2WW referrals (n=12), spinal cases (n=9), records unavailable (n=3). 54 referrals were rejected as non-compliant under 2WW criteria: 30 with chronic symptoms, 20 with benign lesion/normal brain imaging. Compliance with referral information achieved 100% in 1 domain (patient contact details). Details of past medical history, medications, examination and allergies achieved 56–77% compliance. Details of performance status, social history and patient awareness of referral criteria achieved 2–8% compliance.

CONCLUSION

Compliance with the NICE 2WW referral guidelines for brain & CNS cancer is poor. The referral process involves considerable workload for clinical teams especially as 55% of referrals were found to be inappropriate. Compliance may be improved through educational programmes in primary care. Alternatively, by increasing GP access to early cranial imaging, the 2WW pathway could be decommissioned and replaced with a pathway whereby suspected malignancy reported on imaging is linked directly to the neuroscience MDT.